Nokea
When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
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A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
The nurse is teaching a client how to self-administer subcutaneous heparin injections.Which instruction should the nurse include?
- A. Inject in abdominal area at least 2 inches from the umbilicus.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Expel the air in the prefilled syringe prior to injection.
Correct Answer: A
Rationale: Inject in abdominal area at least 2 inches from the umbilicus. When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh. Your tummy is usually best as the injection site and it is important that you change the site each time.
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL'. How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: A
Rationale: Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL', the client should take 15 mL of the suspension per dose. Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.
A postoperative client has been prescribed three different analgesics for different levels of pain.What is the most important intervention the nurse should take when administering these medications to the client?
- A. Administer each medication at the same time to ensure pain relief.
- B. Administer the medication with the highest dose first, then the others.
- C. Administer the medications as ordered based on the client's pain level.
- D. Administer the medication with the longest duration of action
Correct Answer: C
Rationale: The most important intervention the nurse should take when administering these medications to the client is to assess the client's pain level and administer the appropriate medication based on the level of pain.
The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.